Provider Demographics
NPI:1154538007
Name:ANDERSON, ELISE MARIE (LPTA)
Entity type:Individual
Prefix:MS
First Name:ELISE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 N GILLETT ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IL
Mailing Address - Zip Code:62634-6002
Mailing Address - Country:US
Mailing Address - Phone:217-415-6893
Mailing Address - Fax:
Practice Address - Street 1:200 STAHLHUT DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-5066
Practice Address - Country:US
Practice Address - Phone:217-605-5503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS160-000990225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant